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The Field Guide to Understanding Human Error, 2nd Edition by Sidney Dekker

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16 Making Recommendations

Coming up with useful recommendations can be difficult. Sometimes only the shallowest of remedies seem to lie within reach. Tell people to watch out a little more carefully. Write another procedure to regiment their behavior. Or just get rid of the particular miscreants altogether. The limitations of such countermeasures are severe and deep, and well-documented:

  • People will only watch out more carefully for so long, as the novelty and warning of the mishap wears off;
  • A new procedure will at some point clash with operational demands or simply disappear in masses of other regulatory paperwork;
  • Getting rid of the miscreants doesn’t get rid of the problem they got themselves into. Others always seem to be waiting to follow ...

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